A ‘hidden problem’: Nature, prevalence and factors associated with sexual dysfunction in persons living with HIV/AIDS in Uganda

Background We conducted a clinic-based cross-sectional survey among 710 people living with HIV/AIDS in stable ‘sexual’ relationships in central and southwestern Uganda. Although sexual function is rarely discussed due to the private nature of sexual life. Yet, sexual problems may predispose to negative health and social outcomes including marital conflict. Among individuals living with HIV/AIDS, sexual function and dysfunction have hardly been studied especially in sub-Saharan Africa. In this study, we aimed to determine the nature, prevalence and factors associated with sexual dysfunction (SD) among people living with HIV/AIDS (PLWHA) in Uganda. Methods We conducted a clinic based cross sectional survey among 710 PLWHA in stable ‘sexual’ relationships in central region and southwestern Uganda. We collected data on socio-demographic characteristics (age, highest educational attainment, religion, food security, employment, income level, marital status and socio-economic status); psychiatric problems (major depressive disorder, suicidality and HIV-related neurocognitive impairment); psychosocial factors (maladaptive coping styles, negative life events, social support, resilience, HIV stigma); and clinical factors (CD4 counts, body weight, height, HIV clinical stage, treatment adherence). Results Sexual dysfunction (SD) was more prevalent in women (38.7%) than men (17.6%) and majority (89.3% of men and 66.3% of women) did not seek help for the SD. Among men, being of a religion other than Christianity was significantly associated with SD (OR = 5.30, 95%CI 1.60–17.51, p = 0.006). Among women, older age (> 45 years) (OR = 2.96, 95%CI 1.82–4.79, p<0.01), being widowed (OR = 1.80, 95%CI 1.03–3.12, p = 0.051) or being separated from the spouse (OR = 1.69, 95% CI 1.09–2.59, p = 0.051) were significantly associated with SD. Depressive symptoms were significantly associated with SD in both men (OR = 0.27, 95%CI 0.74–0.99) and women (OR = 1.61, 95%CI 1.04–2.48, p = 0.032). In women, high CD4 count (OR = 1.42, 95% CI 1–2.01, p = 0.05) was associated with SD. Conclusion Sexual dysfunction has considerable prevalence among PLWHA in Uganda. It is associated with socio-demographic, psychiatric and clinical illness factors. To further improve the quality of life of PLWHA, they should be screened for sexual dysfunction as part of routine assessment.

1.Your work suffers serious editorial shortcomings, from grammar to in-text citations to referencing style.
Thak you for your comment.The manuscript has been revised and improved.
Throughout the manuscript 2. Methods: ED was measured using 6 items on the IIEF.How was the cut-off score of 25 derived (on a 5-point Likert Scale) which is erroneously presented as a 6-point Likert Scale (Section on Study Variables Line 27)?What informed the cut-off score?Reviewers found fault with sampling techniques and determination of sample size, data collection tools and techniques.Why was the definition for SD different for men and women judging by the fact that authors used a single subscale for men (6 items) and the total FSFI score for women?This has been corrected to a 15 item tool.the cut off score was informed by a previous study (IIEF (Rosen, Riley et al. 1997)) The APA format has been implemented Pages 11,12,13,14,15,16,17,18 When do variables cease to be items and become variables for analysis?What was used in analysis -items in the questionnaire or variables?
Items from the questionnaire were used to generate composite variables for the outcomes.

The references have been revised
Reviewer #3: Abstract: -By taking into account the study period, sampling technique, data collection tools, and statistical methodologies (descriptive or inferential statistics), the authors needed to update the methods part of the abstract once more in light of their objectives.
The methods section of the abstract has been revised.We added that 'Statistical analyses were conducted using Stata release 15, separately for males and females.Frequencies to the FSFI and IIEF were estimated with their percentages.Categorical variables were described using frequencies and percentages while continuous variables were described using median (IQR).Two binary outcome variables "sexual dysfunction for men and sexual dysfunction for women" were generated.
To investigate the association of sexual dysfunction with sociodemographic and psychosocial and psychiatric illness factors, a two-step procedure was adopted.During the first step, bivariate associations between each of the outcome variables and the independent variables were assessed using simple logistic regression models.In the second step, those sociodemographic, psychosocial and psychiatric illness factors that attained a level of significance of P ≤ 0.2 (liberal cut-off point) with bivariate analyses were included in the final multivariate logistic regression models that assessed for the factors that were independently significantly associated with sexual dysfunction.
We were not able to conduct subgroup analyses by homo-and heterosexual respondents) -The authors must indicate the percentage with a 95% confidence interval for the prevalence of sexual disfunction for males and females, respectively.

This has been incorporated
Page 12 -In light of their findings, the authors ought to revise their recommendations.
Although SD exists in both female and male patients with HIV, there need for specific interventions for the different genders.

Introduction:
-The introduction section focuses primarily on the definition, nature, and determinants of sexual dysfunction, with little to no discussion of its prevalence.I should suggest that the authors review the global literature on the prevalence in order to briefly explain the epidemiology (the distribution) of sexual dysfunction.
The section has been revised to include information on the global burden of SD 5 Methods: -When was this study done?considering that the information came from a secondary source and that the patients with HIV/AIDS were chosen from medical records from what years?-In addition to mentioning that this research was conducted as part of Prof Eugene Kinyanda's Senior EDCTP Fellowship funded study entitled, 'Clinical trials in HIV/AIDS in Africa: Should they routinely control for mental health factors?',I believe the authors missed an important section of the materials and methods section, such as how the participants for the study were selected (sampling technique) and the determination of sample size, data collection tools and techniques, the operational definitions of some concepts, etc.
Thank you for the observation.More details have been added on page 7 of the revised manuscript 7 -The authors should thoroughly discuss the statistical part of how categorical and continuous data are reported, respectively, and for variables in the final multivariate model, the authors should plan the adjusted odds This has been done -Additionally, the authors had to disclose the precise categorization (their levels) of each independent variable measured in addition to stating the scales.Results:

This has been added
Page 11 -I'm not sure why the authors chose to use the median rather than the mean when reporting the age.
We chose the median over mean because the mean did not accurately reflect the central tendency The study did not include any qualitative analysesthis was highlighted in the limitations -The authors should have provided a more thorough summary of the main findings and recommendations based on those findings, particularly for those stakeholders working on behavioural changes related to HIV/AIDS and for concerned policymakers.
At last, the authors produced some excellent work, but they should pay particular attention to the methods section because the majority of its components are missing.

This has been included
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